Method and apparatus for detection of venous pulsation

ABSTRACT

Methods and systems for detecting venous pulsation are provided. In one embodiment, a metric of the pulse shape of one or more plethysmographic signals is derived and the presence of venous pulsation is detected based on the metric of pulse shape. Examples, of metrics of pulse shape include a skew metric and a ratio of a minima-to-maxima time over a pulse period interval. In an exemplary embodiment, the presence of venous pulsation is detected based on a metric of the pulse shape of one or more plethysmographic signals and on a phase comparison of the plethysmographic signals.

BACKGROUND OF THE INVENTION

1. Field Of The Invention

The present invention relates in general to pulse oximetry, and inparticular to the processing of signals generated by a pulse oximeter.

2. Description Of The Related Art

A pulse oximeter is typically used to measure various bloodcharacteristics, including the blood oxygen saturation of hemoglobin inarterial blood and the pulse rate of the patient. Measurement of thesecharacteristics has been accomplished by use of a non-invasive sensorthat passes light through a portion of a patient's blood perfused tissueand photo-electrically senses the absorption and scattering of light insuch tissue. The amount of light absorbed and scattered is then used toestimate the amount of blood constituent in the tissue using variousalgorithms known in the art. The “pulse” in pulse oximetry comes fromthe time varying amount of arterial blood in the tissue during a cardiaccycle. The signal processed from the sensed optical measurement is thefamiliar plethysmographic waveform, which corresponds with the cyclicattenuation of optical energy through a portion of a patient's bloodperfused tissue.

Venous pulsation is an undesirable artifact in pulse oximetry. Venouspulsation is particularly common on the head or forehead, where thevascular anatomy lacks valves to prevent venous blood from backing upand pooling. Venous pulsation may be caused by the patient's medicalcondition, or during surgical interventions that interfere with venousreturn. The effects of venous pulsation may include: 1) oxygensaturation (e.g., SpO₂) readings reflecting a mix of venous and arterialblood, which would be substantially lower than the arterial oxygensaturation, thus resulting in incorrectly low oxygen saturationmeasurements, and 2) pulse rate readings that are double or even triplethe patient's pulse rate, due to the prominent harmonics in the venouspressure wave. In addition, in extreme cases, it is possible that anoximeter would fail to acquire oxygen saturation and/or pulse ratemeasurements. Unlike motion artifacts that may be intermittent, venouspulsation can continue uninterrupted for hours. While the side effectsof venous pulsation are highly visible to the clinician, their cause maynot be.

SUMMARY

Certain aspects commensurate in scope with the originally claimedinvention are set forth below. It should be understood that theseaspects are presented merely to provide the reader with a brief summaryof certain forms of the invention might take and that these aspects arenot intended to limit the scope of the invention. Indeed, the inventionmay encompass a variety of aspects that may not be set forth below.

There is provided a method for detecting venous pulsation. The methodincludes the act of deriving a skew metric for one or moreplethysmographic signals. The presence of venous pulsation is detectedbased on the skew metric. Corresponding systems and tangible, machinereadable media are also provided.

There is provided an additional method for detecting venous pulsation.The method includes the act of deriving a ratio of a minima-to-maximatime over an entire pulse period time of one or more plethysmographicsignals. The presence of venous pulsation is detected based on theratio. Corresponding systems and tangible, machine readable media arealso provided.

There is provided a further method for detecting venous pulsation. Themethod includes the act of deriving a metric of the pulse shape of oneor more plethysmographic signals. A phase comparison of theplethysmographic signals is also derived. The presence of venouspulsation is detected based on the metric of the pulse shape and thephase comparison. Corresponding systems and tangible, machine readablemedia are also provided.

BRIEF DESCRIPTION OF THE DRAWINGS

Advantages of the invention may become apparent upon reading thefollowing detailed description and upon reference to the drawings inwhich:

FIG. 1 illustrates a pulse oximetry system coupled to a multi-parameterpatient monitor and a sensor according to embodiments of the presentinvention;

FIG. 2 is a block diagram of an exemplary pulse oximetry model connectedto a sensor according to the present techniques;

FIG. 3 is a flow chart of exemplary actions associated with detectingvenous pulsations according to an embodiment of the present invention;

FIG. 4 is a flow chart of exemplary actions associated with detectingvenous pulsations according to another embodiment of the presentinvention; and

FIG. 5 is a graph showing the results obtained in detecting venouspulsations according to an embodiment of the present invention.

DETAILED DESCRIPTION OF SPECIFIC EMBODIMENTS

One or more specific embodiments of the present invention will bedescribed below. In an effort to provide a concise description of theseembodiments, not all features of an actual implementation are describedin the specification. It should be appreciated that in the developmentof any such actual implementation, as in any engineering or designproject, numerous implementation-specific decisions must be made toachieve the developers' specific goals, such as compliance withsystem-related and business-related constraints, which may vary from oneimplementation to another. Moreover, it should be appreciated that sucha development effort might be complex and time consuming, but wouldnevertheless be a routine undertaking of design, fabrication, andmanufacture for those of ordinary skill having the benefit of thisdisclosure.

The present techniques relate to detection of venous or mixed venous andarterial pulsation in blood perfused tissue. The embodiments of thepresent invention provide methodologies, including software-basedmethods for detecting the venous pulsation artifact. The detection ofthe presence of venous pulsation enables an oximeter to notify aclinician, who could then address and/or correct the problem.

A pulse oximeter typically measures two physiological parameters,percent oxygen saturation of arterial blood hemoglobin (SpO₂) and pulserate. Oxygen saturation can be estimated using various techniques. Inone common technique, the photocurrent generated by the photo-detectormay be conditioned and processed to determine the ratio of modulationratios (ratio of ratios) of the red to infrared (IR) signals. Thismodulation ratio has been observed to correlate well to arterial oxygensaturation. Pulse oximeters and sensors may be empirically calibrated bymeasuring the modulation ratio over a range of in vivo measured arterialoxygen saturations (SaO₂) on a set of patients, healthy volunteers, oranimals. The observed correlation may be used in an inverse manner toestimate blood oxygen saturation (SpO₂) based on the measured value ofmodulation ratios of a patient. The estimation of oxygen saturationusing modulation ratios is described in U.S. Pat. No. 5,853,364,entitled “METHOD AND APPARATUS FOR ESTIMATING PHYSIOLOGICAL PARAMETERSUSING MODEL-BASED ADAPTIVE FILTERING,” issued Dec. 29, 1998, and U.S.Pat. No. 4,911,167, entitled “METHOD AND APPARATUS FOR DETECTING OPTICALPULSES,” issued Mar. 27, 1990, which are both herein incorporated byreference in their entirety for all purposes. The relationship betweenoxygen saturation and modulation ratio is described, for example, inU.S. Pat. No. 5,645,059, entitled “MEDICAL SENSOR WITH MODULATEDENCODING SCHEME,” issued Jul. 8, 1997, which is herein incorporated byreference in its entirety for all purposes. Most pulse oximeters extractthe plethysmographic signal having first determined saturation or pulserate, both of which are susceptible to interference.

FIG. 1 illustrates one embodiment of a pulse oximetry system that may beconfigured to implement the embodiments of the present invention. Apulse oximetry monitor 10 may be used in conjunction with a sensor 12.It should be appreciated that the cable 14 of the sensor 12 may becoupled to the monitor 10 or it may be coupled to a transmission device(not shown) to facilitate wireless transmission between the sensor 12and the monitor 10. The monitor 10 may be any suitable pulse oximeter,such as those available from Nellcor Puritan Bennett Inc. Furthermore,to upgrade conventional pulse oximetry provided by the monitor 10 toprovide additional functions, the monitor 10 may be coupled to amulti-parameter patient monitor 16 via a cable 18 connected to a sensorinput port or via a cable 20 connected to a digital communication port.

FIG. 2 is a block diagram of one embodiment of a pulse oximeter that maybe configured to implement the embodiments of the present invention.Sensor 12 may contain an emitter 52 and a detector 54. Light from anemitter 52 passes into blood perfused tissue of a patient 50 and isscattered then detected by a detector 54. The emitter 52 and thedetector 54 may be disposed on a sensor body, which may be made of anysuitable material, such as plastic, foam, woven material, or paper.Alternatively, the emitter 52 and the detector 54 may be remotelylocated and optically coupled to the sensor 12 using optical fibers. Inthe depicted embodiments, the sensor 12 is coupled to a cable 14 that isresponsible for transmitting electrical and/or optical signals to andfrom the emitter 52 and detector 54 of the sensor 12. The cable 14 maybe permanently coupled to the sensor 12, or it may be removably coupledto the sensor 12, the latter alternative being more useful and costefficient in situations where the sensor 12 is disposable.

The sensor 12 may be a “transmission type” sensor. Transmission typesensors include an emitter 52 and detector 54 that are typically placedon opposing sides of the sensor site. If the sensor site is a fingertip,for example, the sensor 12 is positioned over the patient's fingertipsuch that the emitter 52 and detector 54 lie on either side of thepatient's nail bed. In other words, the sensor 12 is positioned so thatthe emitter 52 is located on the patient's fingernail and the detector54 is located 180° opposite the emitter 52 on the patient's finger pad.During operation, the emitter 52 shines one or more wavelengths of lightthrough the patient's fingertip and the light received by the detector54 is processed to determine various physiological characteristics ofthe patient. In each of the embodiments discussed herein, it should beunderstood that the locations of the emitter 52 and the detector 54 maybe exchanged. For example, the detector 54 may be located at the top ofthe finger and the emitter 52 may be located underneath the finger. Ineither arrangement, the sensor 12 will perform in substantially the samemanner.

Reflectance type sensors also operate by emitting light into the tissueand detecting the light that is transmitted and scattered by the tissue.However, reflectance type sensors include an emitter 52 and detector 54that are typically placed on the same side of the sensor site. Forexample, a reflectance type sensor may be placed on a patient'sfingertip or foot such that the emitter 52 and detector 54 layside-by-side. Reflectance type sensors detect light photons that arescattered back to the detector 54. A sensor 12 may also be a“transflectance” sensor, such as a sensor that may subtend a portion ofa baby's heel.

Emitter 52 and detector 54 may be of any suitable type. For example, theemitter 52 may be one or more light emitting diodes adapted to transmitone or more wavelengths of light in the red to infrared range, and thedetector 54 may be one or more photodetectors selected to receive lightin the range or ranges emitted from the emitter 52. Alternatively,emitter 52 may also be a laser diode or a vertical cavity surfaceemitting laser (VCSEL). Emitter 52 and detector 54 may also includeoptical fiber sensing elements. An emitter 52 may include a broadband or“white light” source, in which case the detector could include any of avariety of elements for selecting specific wavelengths, such asreflective or refractive elements or interferometers. These kinds ofemitters and/or detectors would typically be coupled to the rigid orrigidified sensor via fiber optics. Alternatively, a sensor 12 may senselight detected from the tissue at a different wavelength from the lightemitted into the tissue. Such sensors may be adapted to sensefluorescence, phosphorescence, Raman scattering, Rayleigh scattering andmulti-photon events or photoacoustic effects.

For pulse oximetry applications using either transmission or reflectancetype sensors, the oxygen saturation of the patient's arterial blood maybe determined using two or more wavelengths of light, most commonly redand near infrared wavelengths. Similarly, in other applications, atissue water fraction (or other tissue constituent related metric) or aconcentration of one or more biochemical components in an aqueousenvironment may be measured using two or more wavelengths of light. Incertain embodiments, these wavelengths may be infrared wavelengthsbetween about 1,000 nm to about 2,500 nm. It should be understood that,as used herein, the term “light” may refer to one or more of ultrasound,radio, microwave, millimeter wave, infrared, visible, ultraviolet, gammaray or X-ray electromagnetic radiation, and may also include anywavelength within the radio, microwave, infrared, visible, ultraviolet,or X-ray spectra, and that any suitable wavelength of light may beappropriate for use with the present techniques.

Sensor 12 containing emitter 52 and detector 54 may also contain anencoder 56 that provides signals indicative of the wavelength of emitter52 to allow the oximeter to select appropriate calibration coefficientsfor calculating oxygen saturation. The encoder 56 may, for instance, bea resistor.

The sensor 12 may be connected to a pulse oximetry monitor 10. Themonitor 10 includes a microprocessor 58 connected to an internal bus 60.Also connected to the bus are a read-only memory (ROM) 62, a randomaccess memory (RAM) 64, a display 66, and control inputs 68. A timeprocessing unit (TPU) 70 provides timing control signals to a lightdrive circuitry 72 which controls when the emitter 52 is illuminated,and if multiple light sources are used, the multiplexed timing for thedifferent light sources. TPU 70 also controls the gating-in of signalsfrom detector 54 through an amplifier 74 and a switching circuit 76.These signals are sampled at the proper time, depending upon which ofmultiple light sources is illuminated, if multiple light sources areused. The received signal from the detector 54 may be passed through anamplifier 78, a low pass filter 80, and an analog-to-digital converter82. The digital data may then be stored in a queued serial module (QSM)84, for later downloading to RAM 64 as QSM 84 fills up. In oneembodiment, there may be multiple parallel paths of separate amplifier,filter and A/D converters for multiple light wavelengths or spectrareceived.

Based on the value of the received signals corresponding to the lightreceived by detector 54, microprocessor 58 will calculate the oxygensaturation using various algorithms. These algorithms use coefficients,which may be empirically determined, corresponding to, for example, thewavelengths of light used. Signals indicative of the wavelengths oflight used may be transmitted from the encoder 56 to a decoder 86. Thedecoder 86 translates these signals and determines which coefficientsare needed for the various algorithms. These coefficients are stored inROM 62. In a two-wavelength system, the particular set of coefficientschosen for any pair of wavelength spectra may be determined by the valueindicated by the encoder 56 corresponding to a particular light sourcein a particular sensor 12. In one embodiment, multiple resistor valuesmay be assigned to select different sets of coefficients. In anotherembodiment, the same resistors are used to select from among thecoefficients appropriate for an infrared source paired with either anear red source or far red source. The selection between whether thenear red or far red set will be chosen can be selected with a controlinput from control inputs 68. Control inputs 68 may be, for instance, aswitch on the pulse oximeter, a keyboard, or a port providinginstructions from a remote host computer. Furthermore, any number ofmethods or algorithms may be used to determine a patient's pulse rate,oxygen saturation or any other desired physiological parameter. Theseparameters may then be displayed on display 66. Additionally, in oneembodiment of the present invention, a notification of venous pulsationmay be displayed on display 66.

FIG. 3 is a flow chart illustrating the process by which venouspulsation may be detected using the phase difference between signalwaveforms, according to one embodiment of the present invention. Mixedvenous and arterial pulses may be distinguished from arterial pulses.First, venous blood has a lower saturation than arterial blood. Normoxicsubjects (i.e., healthy subjects breathing air at sea level) who placetheir head significantly below their heart may readily create SpO₂readings near 80% at the forehead if no pressure is applied to thesensor site. Second, the venous pulse occurs after the arterial pulse,and has a different shape. Due to these properties, the IR and redwaveforms will have a significant and persistent phase difference ifthey include venous pulsation. On the other hand, the IR and redwaveforms will be in-phase if they only include arterial pulses. Therelationship between venous pulsation and waveform phase differences isdescribed in U.S. Pat. App. Pub. No. 2005/0197579, entitled “METHOD ANDAPPARATUS FOR OPTICAL DETECTION OF MIXED VENOUS AND ARTERIAL BLOODPULSATION IN TISSUE,” published Sep. 8, 2005, which is hereinincorporated by reference in its entirety for all purposes.

A waveform that may be better suited for detecting phase differencesbetween IR and red waveforms is one that contains just the waveformcorresponding to the fundamental of the pulse rate, such as may beproduced by an appropriate filter. Such a waveform may be better suitedfor detecting phase differences between the IR and red waveforms thatare of vascular origin. As illustrated in FIG. 3, one or more digital IRand red waveforms 100 are AC-coupled, so that they are both zero-mean,and filtered (Block 104) based on a pulse rate 102.

One or more filtered waveforms 106 may then be used to quantify thephase difference (Block 108), which may be characterized by the opennessof the ellipse on a Lissajous plot. Over a time-window of at least onecomplete pulse, an “openness of the ellipse” metric 110 may bequantified as (minimum distance from the origin)/(maximum distance fromthe x-axis). Alternatively the denominator of this ratio may be themaximum distance from the origin. A longer time-window will increase thelikelihood that motion artifact or Gaussian noise would eventuallyproduce samples near the origin, and reduce the likelihood of falselyreporting venous pulsation. This “openness of the ellipse” metric 110may be calculated as follows:

${{Open\_ Lissajous}{\_ Axis}{\_ Ratio}} = \sqrt{\frac{\begin{matrix}{\min\left( {\left( {{IR}_{t}^{2} + {Red}_{t}^{2}} \right),{\left( {{IR}_{t - 1}^{2} + {Red}_{t - 1}^{2}} \right)\mspace{11mu} \ldots}} \right.} \\\left. \left( {{IR}_{t - N + 1}^{2} + {Red}_{t - N + 1}^{2}} \right) \right)\end{matrix}}{\max \left( {{IR}_{t}^{2},{{IR}_{t - 1}^{2}\mspace{11mu} \ldots \mspace{11mu} {IR}_{t - N + 1}^{2}}} \right)}}$

where IR and Red refer to the filtered waveforms 106 and N denotes thenumber of samples in the time-window.

In one embodiment, this metric may be computed periodically (e.g., everysecond) from the most recent time window (e.g., four seconds) of data.It therefore covers a window of about several pulses. A time window ofabout four seconds may assure that the waveforms have multiple pulseperiods in which to come close to the origin if the waveforms areactually in-phase. The inclusion of the red data only in the numeratormakes this metric more sensitive to out-of-phase waveforms at lowsaturations, where the red modulation is larger, than at highsaturations.

Because the “openness of the ellipse” metric 110 may be fairly noisy, itmay be filtered, clipped and integrated (Block 114) before being used toannounce the presence or absence of venous pulsation. The filtering,clipping and integration are described below, such that a venouspulsation integral 116 may be calculated as follows:

$w = {\min\left( {\frac{0.005}{{{{Open\_ Lissajous}{\_ Axis}{\_ Ratio}} - {{Open\_ Lissajous}{\_ Axis}{\_ Ratio}^{\prime}}}},1.0} \right)}$Filt_Open_Lissajous_Axis_Ratio = w * Open_Lissajous_Axis_Ratio + (1-w) * Filt_Open_Lissajous_Axis_Ratio^(′)Filt_Open_Lissajous_Axis_Ratio = min (Filt_Open_Lissajous_Axis_Ratio, 0.3)Open_Lissajous_Threshold = max (0.06, 0.06 + 0.5 * (Saturation − 09.))Venous_Pulsation_Integral = Venous_Pulsation_Integral^(′) + Filt_Open_Lissajous_Axis_Ratio − Open_Lissajous_ThresholdVenous_Pulsation_Integral = min (2.0, max (0, Venous_Pulsation_Integral))

where “′” denotes the value from one second ago, and Saturation is theoxygen saturation value (SpO₂) scaled from zero to 1.0. TheOpen_Lissajous_Threshold metric controls how open the ellipse must be toeventually notify the user of venous pulsation. The threshold may varywith the calculated SpO₂, because venous pulsation is less likely to beoccurring if high SpO₂ values are being calculated.

The venous pulsation integral 116 may be analyzed against a threshold todetermine whether venous pulsation may be present (Block 118). In oneembodiment, using the above approach, the presence of venous pulsationmay be reported (Block 120) if the venous pulsation integral 116 is atleast 1.0, and the presence of venous pulsation may not be reported(Block 122) if the integral 116 is less than 1.0.

In accordance with another embodiment of the present invention, FIG. 4is a flow chart illustrating the process by which venous pulsation maybe detected using the skewness of the pulse shape. In the presence ofonly arterial pulsation, the photo-plethysmographic signal decreasesquickly then increases slowly. In the presence of venous pulsation or amixed arterial and venous pulsation, the signal decreases slowly andincreases quickly. One pulse-shape metric that may be used todiscriminate between these shape differences is the skewness of thederivative of the plethysmograph.

One or more digital IR and red waveforms 150 may be bandpassed,normalized, and whitened (Block 152) to produce one or more filteredwaveforms 154. These filtered waveforms 154 may then be used tocalculate (Block 156) a skew metric 158. Components of the skew metric158 may be calculated as follows:

${{IR\_ Skew} = \frac{n{\sum\left( {x_{t} - \overset{\_}{x}} \right)^{3}}}{\left( {n - 1} \right)\left( {n - 2} \right)\sigma^{3}}},{x = {{IR}_{t} + {2*\left( {{IR}_{t} - {IR}_{t - 1}} \right)}}}$${{Mixed\_ Skew} = \frac{n{\sum\left( {x_{t} - \overset{\_}{x}} \right)^{3}}}{\left( {n - 1} \right)\left( {n - 2} \right)\sigma^{3}}},{x = {\left( {{IR}_{t} - {c_{1}*{Red}_{t}}} \right) + {2*\left( {\left( {{IR}_{t} - {c_{1}*{Red}_{t}}} \right) - \left( {{IR}_{t - 1} - {c_{1}*{Red}_{t - 1}}} \right)} \right)}}}$

where IR and Red refer to the filtered infrared waveforms 154, n is thenumber of samples in 3 seconds at the filter's sampling interval, σ isstandard deviation of x, and t is in samples. Using these components,the skew metric 158 may then be calculated as follows:

${Skew} = {{\left( {1 - \frac{w}{0.55}} \right)*{IR\_ Skew}} + {\left( \frac{w}{0.55} \right)*{Mixed\_ Skew}}}$

where w is a mixing weight that may be varied between 0 and c₁ so as toreduce the Skew metric. In one embodiment, c₁ may have a value of 0.55.

The skew metric 158 may then be averaged and adjusted (Block 160) tocompensate for typical rate-dependent changes in the skewness of humanarterial waveforms. Because venous and arterial pulse shapes tend tohave different derivatives of skewness with respect to rate, a filteredskew metric 162 may be further adjusted (Block 166) based on a pulserate 164, according to the following calculation:

${Adj\_ Skew} = {\max \left( {{Filt\_ Skew},{{Filt\_ Skew} + {0.6*\frac{{Rate} - 100.0}{Rate}}}} \right)}$

where Filt_Skew is the filtered skew metric 162, Rate is the pulse rate164, and Adj_Skew is an adjusted skew metric 168.

The adjusted skew metric 168 may then be further adjusted (Block 172)based on a comparison to the skewness of the derivative of the IRplethysmographic signal 170 according to the following calculation:

${Adj\_ Skew} = \frac{\min \left( {{Adj\_ Skew},{{Deriv\_ Skew} + 0.8}} \right)}{6.0}$

where Deriv_Skew is the skewness of the derivative of the IRplethysmograph 170.

Venous pulsation may then be detected (Block 174) if the adjusted skewmetric determined by the comparison 172 exceeds a predeterminedthreshold. In one embodiment, venous pulsation may be reported when ithas been detected, and not reported if the adjusted skew metricdetermined by the comparison 172 goes below a predetermined threshold,such as an empirically determined threshold.

In an alternative embodiment of the present invention, the presence ofvenous pulsation may be detected using the time ratio metric quantifiedas (minima-to-maxima time of the plethysmographic signal)/(entire pulseperiod). In this embodiment, the presence of venous pulsation may bereported if the ratio of minima-to-maxima time over the entire pulseperiod is less than a predetermined threshold, such as an empiricallydetermined threshold.

In a further embodiment of the present invention, the “openness of theellipse” metric 100 and adjusted skew metric 168 described in relationto FIGS. 3 and 4 may be combined to assess the presence of venouspulsation. This assessment may be performed using the followingcalculations:

VP_Metrics_Threshold = max (0.00, 0.00 + 0.4 * (Saturation − 0.9))w = min (Pulse_Amp_Ratio, 1.0)Venous_Pulsation_Integral = Venous_Pulsation_Integral^(′) + w * (Filt_Open_Lissajous_Axis_Ratio + Adj_Skew − VP_Metrics_Threshold)Venous_Pulsation_Integral = max (0, min (2.0, Venous_Pulsation_Integral))

where “′” denotes the value from one second ago, Saturation is theoxygen saturation value (SpO₂) and Pulse_Amp_Ratio is the ratio ofcurrent pulse amplitude to historical pulse amplitude.

The presence of venous pulsation may be reported if the venous pulsationintegral is at least 1.0, and the presence of venous pulsation may notbe reported if the integral is less than 1.0. This combined phase andshape metric may produce results better than those produced with eithersingle metric, as shown in FIG. 5.

FIG. 5 is a graphic illustration of a simplified set of results oftrials testing the detection of venous pulsation. An axis 200 depictsthe shape metric and an axis 202 depicts the phase metric. Good datapoints 204 represent the patient trials where digit (arterial) andforehead (possibly arterial and/or venous) SpO₂ measurements agreed towithin 4-5 points. Bad data points 206 represent the patient trialswhere digit and forehead SpO₂ measurements were more discrepant.

A horizontal line 208 depicts the venous pulsation classificationthreshold using only the phase metric, according to one embodiment ofthe present invention, such that venous pulsation would be detected forphase metric readings above the line 208. A vertical line 210 depictsthe venous pulsation classification threshold using only the skewmetric, according to another embodiment of the present invention, suchthat venous pulsation would be detected for shape metric readings to theright of the line 210. A diagonal line 212 depicts the venous pulsationclassification threshold using a combination of the phase and skewmetrics according to a further embodiment of the present invention.

It can be seen from this graph that venous pulsation has a higherincidence of being indicated using a combination of the phase andmetrics than using either metric alone. In addition, where venouspulsation is not occurring, there is a lower incidence of incorrectnotification when both phase and shape metrics are used.

While the invention may be susceptible to various modifications andalternative forms, specific embodiments have been shown by way ofexample in the drawings and have been described in detail herein.However, it should be understood that the invention is not intended tobe limited to the particular forms disclosed. Indeed, the presenttechniques may not only be applied to measurements of blood oxygensaturation, but these techniques may also be utilized for themeasurement and/or analysis of other blood constituents. For example,using the same, different, or additional wavelengths, the presenttechniques may be utilized in conjunction with the measurement and/oranalysis of carboxyhemoglobin, met-hemoglobin, total hemoglobin,intravascular dyes, and/or water content. Likewise, the technique may beemployed using other techniques for measuring pulse shape, differentsequences of filtering, different constants, and so forth. The inventionis to cover all modifications, equivalents, and alternatives fallingwithin the spirit and scope of the invention as defined by the followingappended claims.

1. A method for detecting venous pulsation, comprising: deriving a skewmetric for one or more plethysmographic signals; and detecting thepresence of venous pulsation based on the skew metric.
 2. The method ofclaim 1, wherein the skew metric comprises a measure of the skewness ofthe derivative of one or more plethysmographic signals.
 3. The method ofclaim 1, wherein the skew metric is processed to compensate for thetypical rate-dependent changes in the skewness of arterial waveforms. 4.The method of claim 1, wherein the skew metric is adjusted based on apulse rate.
 5. The method of claim 1, wherein detecting the presence ofvenous pulsation comprises: deriving a skew of the plethysmographicsignal after filtering with a first set of filters; and comparing theskew metric to the skew of the plethysmographic signal after filteringwith a second set of filters .
 6. The method of claim 1, comprisingproviding a notification of the presence of venous pulsation whendetected.
 7. A method for detecting venous pulsation, comprising:deriving a ratio of a minima-to-maxima time over an entire pulse periodtime of one or more plethysmographic signals; and detecting the presenceof venous pulsation based on the ratio.
 8. A method for detecting venouspulsation, comprising: deriving a metric of the pulse shape of one ormore plethysmographic signals; deriving a phase comparison of theplethysmographic signals; and detecting the presence of venous pulsationbased on the metric of the pulse shape and the phase comparison.
 9. Themethod of claim 8, wherein the metric of the pulse shape comprises ameasure of the skewness of the derivative of the one or moreplethysmographic signals.
 10. The method of claim 8, wherein the phasecomparison comprises a measure of the openness of a Lissajous plotformed by comparing the one or more plethysmographic signals.
 11. Themethod of claim 8, wherein the metric of the pulse shape comprises theratio of a minima-to-maxima time over an entire pulse period interval ofthe one or more plethysmographic signals.
 12. The method of claim 8,wherein detecting the presence of venous pulsation comprises combiningthe metric of the pulse shape and the phase comparison to calculate avenous pulsation metric.
 13. The method of claim 12, wherein detectingthe presence of venous pulsation comprises comparing the venouspulsation metric to a threshold value.
 14. The method of claim 8,further comprising providing a notification of the presence of venouspulsation when detected.
 15. One or more tangible, machine readablemedia, comprising code executable to perform the acts of: deriving askew metric for one or more plethysmographic signals; and detecting thepresence of venous pulsation based on the skew metric.
 16. The tangible,machine readable media of claim 15, further comprising code executableto perform the act of processing the skew metric to compensate for thetypical rate-dependent changes in the skewness of arterial waveforms.17. The tangible, machine readable media of claim 15, further comprisingcode executable to perform the act of adjusting the skew metric based ona pulse rate.
 18. The tangible, machine readable media of claim 15,further comprising code executable to perform the acts of: deriving askew of the plethysmographic signal after filtering with a first set offilters; and comparing the skew metric to the skew of theplethysmographic signal after filtering with a second set of filters.19. The tangible, machine readable media of claim 15, further comprisingcode executable to perform the acts of providing a notification of thepresence of venous pulsation when detected.
 20. One or more tangible,machine readable media, comprising code executable to perform the actsof: deriving a ratio of a minima-to-maxima time over an entire pulseperiod time of one or more plethysmographic signals; and detecting thepresence of venous pulsation based on the ratio.
 21. The tangible,machine readable media of claim 20, further comprising code executableto perform the acts of providing a notification of the presence ofvenous pulsation when detected.
 22. One or more tangible, machinereadable media, comprising code executable to perform the acts of:deriving a metric of the pulse shape of one or more plethysmographicsignals; deriving a phase comparison of the plethysmographic signals;and detecting the presence of venous pulsation based on the metric ofthe pulse shape and the phase comparison.
 23. The tangible, machinereadable media of claim 22, wherein the metric of the pulse shapecomprises a measure of the skewness of the derivative of the one or moreplethysmographic signals.
 24. The tangible, machine readable media ofclaim 22, wherein the phase comparison comprises a measure of theopenness of a Lissajous plot formed by comparing the one or moreplethysmographic signals.
 25. The tangible, machine readable media ofclaim 22, wherein the metric of the pulse shape comprises the ratio of aminima-to-maxima time over an entire pulse period time of the one ormore plethysmographic signals.
 26. The tangible, machine readable mediaof claim 22, further comprising code executable to perform the acts ofcombining the metric of the pulse shape and the phase comparison tocalculate a venous pulsation metric.
 27. The tangible, machine readablemedia of claim 26, further comprising code executable to perform theacts of comparing the venous pulsation metric to a threshold value. 28.The tangible, machine readable media of claim 22, further comprisingcode executable to perform the acts of providing a notification of thepresence of venous pulsation when detected.
 29. A patient monitoringsystem comprising: a patient monitor configured to: derive a skew metricfor one or more plethysmographic signals; and detect the presence ofvenous pulsation based on the skew metric.
 30. The system of claim 29,wherein the patient monitor is configured to process the skew metric tocompensate for the typical rate-dependent changes in the skewness ofarterial waveforms.
 31. The system of claim 29, wherein the patientmonitor is configured to adjust the skew metric based on pulse rate. 32.The system of claim 29, wherein detecting the presence of venouspulsation comprises: deriving a skew of the plethysmographic signalafter filtering with a first set of filters; and comparing the skewmetric to the skew of the plethysmographic signal after filtering with asecond set of filters.
 33. The system of claim 29, wherein the patientmonitor is configured to provide a notification of the presence ofvenous pulsation when detected.
 34. A patient monitoring systemcomprising: a patient monitor configured to: derive a metric of thepulse shape of one or more plethysmographic signals; derive a phasecomparison of the plethysmographic signals; and detect the presence ofvenous pulsation based on the metric of the pulse shape and the phasecomparison.
 35. The system of claim 34, wherein the metric of the pulseshape comprises a measure of the skewness of the derivative of the oneor more plethysmographic signals.
 36. The system of claim 34, whereinthe phase comparison comprises a measure of the openness of a Lissajousplot formed by comparing the one or more plethysmographic signals. 37.The system of claim 34, wherein the metric of the pulse shape comprisesthe ratio of a minima-to-maxima time over an entire pulse period time ofthe one or more plethysmographic signals.
 38. The system of claim 34,wherein detecting the presence of venous pulsation comprises combiningthe metric of the pulse shape and the phase comparison to calculate avenous pulsation metric.
 39. The system of claim 39, wherein detectingthe presence of venous pulsation comprises comparing the venouspulsation metric to a threshold value.
 40. The system of claim 34,wherein the patient monitor is configured to provide a notification ofthe presence of venous pulsation when detected.
 41. A patient monitoringsystem comprising: a patient monitor configured to: derive a ratio of aminima-to-maxima time over an entire pulse period time of one or moreplethysmographic signals; and detect the presence of venous pulsationbased on the ratio.